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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name ((ZLL Q ")6-2705447 <br />Phone 41 -� ZZ <br />LAddress <br />14,q E . aw,-- ktev L.", S�Oc k h <br />TCross <br />Street <br />Y <br />Owner/Operator r]iS�� <br />Phone # q I 267 - O20 <br />C <br />Contractor Name 0 i21�5 QE :zoc. <br />Phone # c2 I b <br />T <br />Contractor Address ZS, c Eve A-je �J, Sqz�. R5 <br />CA Lic #,gZ./ Z 2f,,, Class,4 6 Q () C-3/. <br />A <br />Insurer j_,►`b( �� .0 u+,,Z� Etre <br />Work Comp #\W 70 0 004119-7-/1 <br />C <br />T <br />ICC Technician's Name i <br />����.,,`'i' ��u v�c1,Oc.L� <br />Expiration Date '9-8-0 <br />°ICC <br />R <br />Installer's Name Q-0 �je, 01U V&0 c..6L <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />[' Approved Approved with conditions _': Disapproved <br />L <br />A <br />(Se ttachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" <br />Applicant's Signature Title Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME 012055-2 Z1Cill b10 HA & Ii _54 <br />_PHONE #�C� 7 <br />U <br />ADDRESS 2 S i ` <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />TE f —5 —D/ <br />'RIB <br />7 <br />